#KEYLIMEPODCAST 300: Does spaced education improve clinical knowledge among Family Medicine residents? A cluster randomized controlled trial

Jon presents a manuscript that examines space repetition’s effectiveness as an evidence-based learning strategy. In this cluster RCT, the authors tested whether alerts to encourage spaced education could improve clinical knowledge. Listen to the episode to learn more.


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Grad et. al., Does spaced education improve clinical knowledge among Family Medicine residents? A cluster randomized controlled trial. Adv HealthSci Educ Theory Pract. 2021 Jan 3


Jon Sherbino (@sherbino)


This is manuscript title is the perfect union.  Much like chocolate and peanut butter or hockey and beer.  In fact as a point of exclamation, I am not providing an abbreviated title for this episode, I’m sticking with the authors original choice. 

Ok if you follow the show, you know I’m an unapologetic post positivist.  (Truth be known, I just say that to try and get under the skin of my co-host, some of who are open while others are closeted inductive methodologists. Someone has to stick up for “experiments.”).

More than the methodology I’m a huge fan of learning science.  Hence why I chose this paper. Let’s play a fun game, how many evidence-based learning strategies can you name? 

This is not an exhaustive list, but evidence-based learning strategies include: spaced repetition (duh!), retrieval practice, elaboration, interleaving and dual coding (See Mayer for specifics on this.). It does not include learning styles, for which I have strong antibodies as demonstrated on past episodes, re-reading with highlighters, or sleeping with audiorecordings playing in the background.  (I’m not going to go on record about this last one.)

Spaced repetition involves repeated inoculation of information at gradually expanding intervals to ensure retention.  Unlike mass distribution that boluses all of the information at once, spaced repetition helps improve retrieval of information via repeated priming with the material using smaller doses and at longer intervals.

If you’re interested in learning a little bit more about spaced repetition it in health professions education, read on.


The authors state:

We aimed to test whether alerts to encourage spaced education can improve clinical knowledge as measured by scores on the Canadian Family Medicine certification examination.”

Key Points on the Methods

CONSORT guildelines followed.
All English speaking Canadian Family Medicine residency programs recruited. 12 out of 13 programs participated.

Clusters were (training programs) randomized to intervention or control. The intervention was a mobile app based on the Family Medicine Studey Guide, providing a weekly clinical case that required competion of test questions. A t or or 2 week intervals, a reminder to review completed cases was sent until the participant indicated that they were satisfied with their answers on two separate occasions. The control group had access to the app (including cases and questions) but without any prompting / reminder function.

The primary outcome was the score on the short-answer management problem component of the
Canadian Family Medicine certification exam.

A priori determination of educational significance was a difference of 4% points on the exam!

An intention-to-treat analysis was performed.

Key Outcomes

An average of 50 residents (range 15 to 108) were recruited in each cluster. 634 residents were rectuited with 21% lost to follow-up.  There was no differences in demographics.

There was no difference in exam scores.

There was no difference in the number of clinical cases completed over the 16 months of the study. There was more case completion in the intervention group up to day 300 of the study, however, the lower 95%CI margin did not achieve statistical significance.

Key Conclusions

The authors conclude…

“In the current trial, we found no effect of alerts on clinical case completion, consistent with the outcome of no effect on clinical knowledge. A conclusion from this finding is as follows. While repeated exposure to didactic material is important for knowledge retention, we could not show that adding alerts to engage with clinical cases is better than self-paced review alone.”

Spare Keys – other take home points for Clinician Educators

Shout-out to the learningscientists.org. Check out their infographics, materials and podcast, all available under various Creative Commons licenses.

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